CONTACTS 

SUBJECTS
VA EGD Procedure Stricture Lower Esophageal Sphincter Valve LESV 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2503 -    ..
2504 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
2505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250501 - Follow up ref SDS C7 0000. ref SDS C2 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250503 - No diffuculty swallowing this cycle with LESV dilated to 20 mm 5 weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250504 - ago on 200529. ref SDS 0 VV6N  Reported no further aspiration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250505 - problems, waking up choking, after Doctor Lee ordered increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250506 - Mylanta on 190618. ref SDS 0 N27F  Reviewed pending issues, including                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250507 - frequent urination taking Pantoprazole every day, causing dehydration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250508 - now seems stabalized. ref SDS 0 UI5N  Signed blank consent for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250509 - procedure today, on assurance that stroke symptoms following prior EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250510 - on 160617, with mild recurrence on 161213, would not occur by holding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250511 - versed below 6, and aiming for 4 mg. ref SDS 0 639M  EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250512 - procedure was successful with no complications. ref SDS 0 T25I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250513 - Gastroscope in and out took 11 minutes.  The 2nd procecure for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250514 - colonoscopy took 9 minutes, for total of 20 minutes. ref SDS 0 UT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250515 - Versed sedation medication required only 4 mg, well below 6 mg that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250516 - caused prior stroke symptoms. ref SDS 0 CR4F  Post procedure Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250517 - Lee reported good results with LESV contracting to only 19 mm, so he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250518 - was able to dilate LESV back to 20 mm. ref SDS 0 GD5K  Ulcerations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250519 - remain resolved over past 6 weeks, which enabled the doctor to dilate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250520 - LESV needed for better swallowing. ref SDS 0 RZ3G  Continued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250521 - improvement in ulceration and LESV dilation shows good response to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250522 - treatment with prescribed medications. ref SDS 0 JK6N  Colonoscopy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250523 - found no polops nor other indications of cancer.  The doctor reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250524 - 2 small areas confirm diagnosis of ischemic colitis.  He prescribed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250525 - increased hydration during long hikes. ref SDS 0 ZB9N  Scheduled next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250526 - EGD dilation in 8 weeks on 200908 0930. ref SDS 0 XF6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250527 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250528 -            [On 200716 0800 received biopsy report and a letter from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250529 -            Doctor Lee - he also called and said there was colitis at 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250530 -            of the 6 biopsy sites. ref SDS E2 UC5L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
250531 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250535 -  ..
2506 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2507 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2508 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2509 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250901 - On 050629 meeting Primary Care swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250902 - reported. ref SDS 1 K78K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250904 -  ..
250905 - On 050714 barrium swallow test, ref SDS 2 2I4S, showed esophagus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250906 - distorted by swallowing problems. ref SDS 2 WE4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250908 -  ..
250909 - On 050816 meeting Primary Care Doctor Sandhu diagnoses achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250910 - ref SDS 3 DG8G  Ultrasound test ordered to verify initial diagnosis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250911 - swallowing and vomitting problems. ref SDS 3 6E7H  Primary Care made                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
250912 - referral to GI clinic for care to resolve swallowing problems.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250913 - ref SDS 3 0G7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250915 -  ..
250916 - On 050830 ultrasound test evaluate swallowing problems possible                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250917 - diagnosis achalasia. ref SDS 4 DG8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250919 -  ..
250920 - On 050830 results received barrium swallow test performed on 050714,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250921 - findings in the lower espohagus and gastroesophageal junction are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250922 - consistent with achalasia - recommend endoscopic examination.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250923 - ref SDS 4 6H9S                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250925 -  ..
250926 - On 050906 report ultrasound test on 050830, finds no cause for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
250927 - swallowing problems and does not diagnose achalasia. ref SDS 5 BM6R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
250929 -  ..
250930 - On 051202 meeting GI Clinic Doctor Lee diagnoses achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250931 - ref SDS 6 HP9H  Orders endoscopy (EGD) test to verify diagnosis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250932 - achalasia and assess for cancer. ref SDS 6 NZ5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250934 -  ..
250935 - On 051209 GI Clinic endoscopy examination preliminary findings no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250936 - evidence of cancer, ref SDS 7 0001; biopsy report should be submitted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250937 - in a few weeks to confirm status of cancer, ref SDS 7 PY5J, and if so,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250938 - then a procedure can be schedule for next month to dilate the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250939 - exophageal sphincter valve. ref SDS 7 NZ5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250941 -  ..
250942 - On 051222 biopsy reports no evidence of cancer. ref SDS 8 FT6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250944 -  ..
250945 - On 060111 received letter from Doctor Lee in the Gastrointestinal (GI)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250946 - Clinic reporting that the biopsy was negative for cancer and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
250947 - infection; next step is manometry test to verify achalasia, then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250948 - treatment for achalasia. ref SDS 9 4Q3R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250950 -  ..
250951 - On 060125 manomety test scheduled for 060209 0800. ref SDS 10 GG9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250953 -  ..
250954 - On 060209 meeting at VA Mather AFB in Sacramento, test was postponed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250955 - until 060223, due to equipment failure. ref SDS 11 OW6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
250957 -  ..
250958 - On 060221 Jimmy in GI Department at Sacramento VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250959 - reports manometry equipment still broken; has been sent out for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
250960 - repairs and there is no date at this time on when the equipment will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250961 - be available for use at the VA. ref SDS 12 ND7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250963 -  ..
250964 - On 060330 endoscopy follow up examination at GI Department Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250965 - Medical Center - Doctor Lee finds no evidence cancer performed at VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250966 - Sacramento condition precedent treatment recover from achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
250967 - ref SDS 13 VX4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250969 -  ..
250970 - On 060330 manometry test performed by Doctor Lee at VA in Sacramento,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250971 - ref SDS 13 MC7P, verifies diagnosis swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250972 - caused by achalasia, ref SDS 13 MD4N, patient meets criteria for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250973 - treatment with pneumatic dilation. ref SDS 13 MD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250975 -  ..
250976 - On 060505 Martinez VA GI clinic Doctor Lee reported equipment and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
250977 - pneumatic balloon materials on hand to perform dilation for treating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250978 - achalasia; treatment delayed until diagnostic data is received from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
250979 - Sacramento VA Medical Center from manometry test performed on 060330;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250980 - doctor following up to obtain data; will submit test data to patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250981 - during the week of 060508, along with a schedule to treat achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250982 - ref SDS 14 FT6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
250984 -  ..
250985 - On 060614 Martinez VA GI clinic reports increased work load treating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250986 - soldiers returning from war in Iraq requires prioritizing; patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250987 - advocate, Rubin Soto, will coordinate with the GI Clinic notifying the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
250988 - customer of the schedule based on current priorities. ref SDS 15 J86N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
250990 -  ..
250991 - On 070220 letter to VA asks about progress getting test results from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250992 - VA in Sacramento, and scheduling surgery for achalasia, ref SDS 16                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
250993 - 5R5R                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250995 -  ..
250996 - On 090812 1030 continued vomitting achalasia causes weight loss 30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
250997 - pounds in a few months, Primary Care physician notified GI clinic to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
250998 - review schedule for dilation to relieve achalasia. ref SDS 17 7L5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251000 -  ..
251001 - On 090908 meeting GI Clinic in Martinez reports treatment for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251002 - achalasia still waiting to receive results for manometry test on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251003 - 060330, at Sacramento VA Medical Center. ref SDS 18 HX46  Prepared new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251004 - work plan to treat achalasia without manometry test results, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251005 - the doctor performed the test 3 years ago, and is so knows results                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251006 - consistent with achalasia, shown on 060330 0712, ref SDS 13 MD4N;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251007 - schedules treatment for achalasia after treadmill stress test,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251008 - ref SDS 18 BU6W, to evaluate new chest pains hiking hills at Lafayette                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251009 - Reservoir which have not occurred doing extended exercise hiking 3 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251010 - 14 miles a day over the past 5 years. ref SDS 18 MY4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251012 -  ..
251013 - On 091021 report history achalasia issue during meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251014 - cardiothoracic surgery team to prepare for heart bypass surgery the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251015 - next day. ref SDS 19 NX6M  Surgery team will coordinate with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251016 - anesthesia team to provide swallowing relief during heart surgery to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251017 - prevent choking. ref SDS 19 R78O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251019 -  ..
251020 - On 091022 0700 meeting anesthesia team - Doctor Brezinski not familiar                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251021 - with achalasia - asked if achalasia has been reported to the VA?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251022 - ref SDS 20 JF9K  While being prepared with IVs for surgery, patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251023 - assists anesthesia find VA records on achalasia, ref SDS 20 2W4K;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251024 - Doctor Brezenski makes plans for patient care and safety so that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251025 - achalasia does not risk death during heart surgery. ref SDS 20 GX4J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251027 -  ..
251028 - On 091022 cabg x4 cardiothoracic surgery San Francisco Medical Center.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251029 - ref SDS 20 PQWU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251031 -  ..
251032 - On 091030 0800 at 1406 meeting with Doctor Stewart at San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251033 - Medical Center during recovery from heart surgery, proposes Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251034 - Myotomy surgery rather than pneumatic (balloon) dilation as more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251035 - effective and longer lasting solution to recover from swallowing and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251036 - vomitting problems caused by achalasia. ref SDS 21 KE3B                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251038 -  ..
251039 - On 091030 0800 at 1430 received documentation from GI Department at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251040 - San Francisco Medical Center - review shows 3 different treatments for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251041 - achalasia - pills, pneumatic dilation, Heller Myotomy surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251042 - ref SDS 21 495I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251044 -  ..
251045 - On 091030 0800 at 1440 meeting cardiothoracic surgery team; Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251046 - Ratcliff concerned about how to maintain nutrition for the patient to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251047 - recover from heart surgery while digestion remains problematic due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251048 - achalasia; proposes feeding tube for several months until Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251049 - Myotomy surgery. ref SDS 21 03GF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251051 -  ..
251052 - On 091216 Heller Myotomy surgery at San Francisco VA Medical Center to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251053 - recover from achalasia. 091216 0600, ref SDS 22 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251055 -  ..
251056 - On 100202 meeting with Doctor Lee - report swallowing and vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251057 - problems 3 months after Heller Myotomy surgery.  Doctor explains                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251058 - achalasia disease breaks nerve connections from the brain that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251059 - contract the esophagus to force food and liquid from the mouth through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251060 - the esophagus; as well broken nerve connections prevent the lower                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251061 - esophageal sphincter valve (LESV) to relax so that content can pass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251062 - into the stomach.  Without esophageal contractions, food and liquid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251063 - can only reach the stomach with gravity, but since the LESV won't                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251064 - relax the patient continues to have swallowing and vomitting problems,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251065 - despite Heller Myotomy surgery on 091216, intended to maintain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251066 - adequate opening into the stomach. ref SDS 23 485W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251068 -  ..
251069 - On 100305 meeting at GI Clinic in Martinez, EGD procedure dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251070 - from 11 to 15 mm. ref SDS 24 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251072 -  ..
251073 - On 100827 meeting at GI Clinic in Martinez, EGD procedure dilated LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251074 - from 11 to 15 mm. ref SDS 25 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251076 -  ..
251077 - On 101210 EGD procedure dilated esophageal sphincter valve (LESV)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251078 - without sedation, ref SDS 29 BE7K - dilated LESV again from 11 to 14                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251079 - mm. ref SDS 29 BF6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251081 -  ..
251082 - On 101216 1021 letter commends medical team for excellent work, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251083 - confirms schedule next EGD on 110218 0730. ref SDS 30 K35G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251085 -  ..
251086 - On 110218 0730 4th EGD procedure at VA in Martinez, and using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251087 - anesthesia with Fentanyl. ref SDS 31 PQWY  LESV dilated 11 - 14 mm,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251088 - and added triamcinolone steriod injections to resist contraction of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251089 - LESV so that swallowing is maintained over the next 3 month cycle.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251090 - ref SDS 31 SR4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251092 -  ..
251093 - On 110429 0830 5th EGD dilation at VA in Martinez - triamcinolone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251094 - steriod injections worked well to resist contraction of LESV so that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251095 - swallowing was maintained over the prior 3 month cycle, ref SDS 32                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251096 - FE3F, so LESV dilated from 13 - 16.5 mm, ref SDS 32 U23I, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251097 - triamcinolone injections were continued. ref SDS 32 SS5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251099 -  ..
251100 - On 110607 1414 visited GI Department, ref SDS 34 HC5H, and Charlene                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251101 - reported a computer mistakes requires scheduling next EGD dilation on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251102 - 110819 0830. ref SDS 34 N642  Requested meeting with Doctor Lee to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251103 - review pending action items. ref SDS 34 4P6J,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251105 -  ..
251106 - On 110819 0830 EGD and Dilation of stricture at lower esphageal sphincter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251107 - valve.  Triamcinolone steriod injections worked well to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251108 - contraction of LESV so that swallowing is maintained over the prior 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251109 - month cycle, so LESV dilated from 15 - 16.5 mm, ref SDS 35 J978, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251110 - triamcinolone injections were continued. ref SDS 35 J985                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251112 -  ..
251113 - On 111115 1300 EGD dilation procedure - triamcinolone steriod injections                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251114 - worked well over the prior 3 month cycle, so LESV dilated from 16.5 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251115 - 18 mm, ref SDS 36 IR57; for some reason triamcinolone injections to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251116 - resist contraction of LESV was not performed. ref SDS 36 IS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251118 -  ..
251119 - On 111201 0928 seems to be 10% increase in blood pressure the past                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251120 - month, ref SDS 37 ZM5H, beginning on 111030, shown by case study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251121 - 101010 0744. ref SDS 27 UT6K  Case study reports Omeprazole paused on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251122 - 111201. ref SDS 27 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251124 -  ..
251125 - On 120322 1030 notified Doctor Lee during meeting at VA changed dose                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251126 - for Omeprazole to reduce sudden increase from low to high blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251127 - pressure. ref SDS 39 UH5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251129 -  ..
251130 - On 120322 1030 EGD dilation procedure - swallowing and vomitting problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251131 - increased without triamcinolone steriod injections on prior 3 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251132 - cycle. ref SDS 39 UI9H  LESV dilated from 16.5 - 18 mm. ref SDS 39                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251133 - 516N  Triamcinolone injections to resist contraction of LESV was not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251134 - performed. ref SDS 39 5179                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251136 -  ..
251137 - On 120925 0900 meeting Doctor Lee reported schedule mistake using new VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251138 - business unit; reported patient history. ref SDS 40 RG9K  Scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251139 - EGD and dilation procedure for 1300; returned and performed procedure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251140 - ref SDS 40 TB4J; dilated from 15 mm to 18 mm. ref SDS 40 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251141 - Swallowing and vomitting problems increased after omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251142 - triamcinolone steriod injections to resist contraction of LESV after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251143 - dilation, ref SDS 40 TZ4M; therefore, injections were resumed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251144 - complement dilation to enable and maintain effective swallowing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251145 - ref SDS 40 R87N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251147 -  ..
251148 - On 130110 0900 meeting Doctor Lee EGD dilation procedure found                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251149 - improvement recovering from acalasia, LESV contracted only slightly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251150 - from 18 mm down to 15 mm. ref SDS 41 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251152 -  ..
251153 - On 130416 1100 meeting Doctor Lee EGD procedure no dilation required LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251154 - remained at 18 MM, ref SDS 42 CO5N, same as dialated 4 months earlier                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251155 - on 130110 0900. ref SDS 41 Q333  Report CT test on 130117, shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251156 - esophagus fully recovered from severe distortions caused by achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251157 - 8 years earlier. ref SDS 42 MT6F  Doctor Lee injected steriod again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251158 - maintain swallowing. ref SDS 42 F38G  Prescribed reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251159 - to 1 pill per day. ref SDS 42 R74M  Scheduled next EDG dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251160 - months, instead of 3. ref SDS 42 6P6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251162 -  ..
251163 - On 131115 0700 meeting Doctor Lee EGD prodecure dialation LESV from 16.5                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251164 - to 18 mm. ref SDS 43 CO5N  Triamcinolone steriod injected again to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251165 - maintain improved swallowing. ref SDS 43 I167  Omeprazole medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251166 - maintained 20 mg taken morning and evening for 1 month, then reduce to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251167 - 20 mg once per day. ref SDS 43 R74M  Biopsies taken. ref SDS 43 3N8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251169 -  ..
251170 - On 131121 1604 ordered refill of Omeprazole to aid digestion.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251171 - is 1 refill remaining. ref SDS 44 YS4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251173 -  ..
251174 - On 131205 1443 received order for Omeprazole prescription placed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251175 - 131121. ref SDS 45 5N3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251177 -  ..
251178 - On 140318 1043 received letter cancelling meeting scheduled for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251179 - EGD/Dilation procedure on 140425 1000, ref SDS 47 935L; a second                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251180 - letter scheduled prodedure on 140509 0900. ref SDS 47 5D7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251182 -  ..
251183 - On 140401 1659 ordered refill Omeprazole; none are remaining; need                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251184 - Doctor Lee to order new prescription to increase refills. ref SDS 48                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251185 - 4P5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251187 -  ..
251188 - On 140509 0900 meeting Doctor Lee for EGD Dilation at VA medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251189 - center in Sacramento, Mather. ref SDS 49 K37G  Pre-op preperation went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251190 - well - IV setup on first stick. ref SDS 49 EP75  Doctor ordered refills                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251191 - for Omeprazole. ref SDS 49 AW5O  Doctor patient partnership continues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251192 - to progress with doctor reading up on patient history to be prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251193 - for effective meeting. ref SDS 49 ZZ6J  Doctor Lee recalled today                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251194 - having made timely referral for having heart surgery, enabling patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251195 - to recover and Half Dome 4 years later. ref SDS 49 0N6I  Reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251196 - swallowing and vomitting problems reduced past 6 months with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251197 - triamcinolone steriod injections to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251198 - ref SDS 49 VV6N  Doctor Lee dilated LESV contracted to only 16.5 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251199 - over past 6 months with triamcinolone steriod injections to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251200 - contraction; he dilated LESV back to 18 MMy, ref SDS 49 5H5J, scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251201 - next EGD dilation in 6 months since this worked well the past 6 months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251202 - with triamcinolone steriod injections. ref SDS 49 549I  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251203 - explained that since there was no tearing of LESV during procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251204 - today, triamcinolone steriod was not injected into LESV to resist                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251205 - contraction. ref SDS 49 I167  Progress notes report small tearing of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251206 - LESV during dilation procedure. ref SDS 49 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251208 -  ..
251209 - On 140718 1017 planning for notifying VA to update current fill date                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251210 - for Omeprazole. ref SDS 50 U88L  Kathy visited VA in Sacramento, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251211 - requested changing refill date for Omeprazole to 140718. ref SDS 50                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251212 - OL5K  VA representative called customer, and said Doctor Lee would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251213 - call back later that day to consider action on updating scheduled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251214 - refill date of Omeprazole to 140718. ref SDS 50 U76M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251216 -  ..
251217 - On 140810 1839 letter to Doctor Lee requesting EGD dilation with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251218 - triamcinolone injection soonest, if cancellation occurs; but, not an                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251219 - emergency, ref SDS 51 W83K, based on history rising vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251220 - swallowing problems, shown in patient history case study on 120101,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251221 - beginning 140712. ref SDS 38 4E4M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251223 -  ..
251224 - On 140819 0800 during meeting at VA Primary Care Clinic in Martinez,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251225 - Doctor Sandhu indicated Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251226 - will be notified about rising achalasia symptoms for consideration to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251227 - advance EGD dilation procedure. ref SDS 52 EX78                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251229 -  ..
251230 - On 141014 0943 Kathy visited VA Medical Center in Sacramento and met                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251231 - with Lapria again, who advised that the VA responded in a letter on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251232 - 141001, to the letter on 140810, and further scheduled a meeting with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251233 - Doctor Lee on 141121 1530. ref SDS 53 QJ5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251235 -  ..
251236 - On 141103 2152 submitted agenda for meeting with Doctor Lee at VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251237 - Sacramento Medical Center on 141107 0800, for next EGD dilation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251238 - ref SDS 54 K37G  Submit record showing normal swallowing occurs longer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251239 - with triamcinolone steriod injection to resist contraction of LESV.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251240 - ref SDS 54 3U97  Request schedule next EGD dilation in 4 months, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251241 - if LESV does not contract, then schedule following EGD dilation in 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251242 - months. ref SDS 54 3U66  Notified results of Half Dome hike.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251243 - ref SDS 54 3U6Y                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251245 -  ..
251246 - On 141107 0800 EGD dilation procedure - setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251247 - sedation required 3 sticks. ref SDS 55 5W5I  Meeting Doctor Lee guided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251248 - by agenda facilitated collaboration through doctor patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251249 - partnership. ref SDS 55 VV6N  Doctor explained increased difficulty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251250 - swallowing due to experiment omitting triamcinalone steriod injection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251251 - on prior procedure, ref SDS 55 4U8I, shown by LESV contracting back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251252 - from 15 mm. ref SDS 55 T55I  Progress Notes report finding ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251253 - and hiatal hernia. ref SDS 55 MG6N  Photographs seem to show                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251254 - significantly different condition of fundoplication from a year                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251255 - earlier. ref SDS 55 I74I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251257 -  ..
251258 - On 150319 0800 meeting Doctor Lee in GI Clinic VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251259 - Sacramento report swallowing improved with triamcinalone steriod                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251260 - injections on 141107 EGD dilation procedure. ref SDS 56 0M6I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251261 - Lee advised that increased orange juice consumption aids digestion,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251262 - and presents no health risks. ref SDS 56 YF5M  Scheduled next EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251263 - dilation procedure on 150421 1300. ref SDS 56 PS4O  Fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251264 - failure increases acid burn that caused ulceration with hiatal hernia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251265 - with increased recurrance achalasia. ref SDS 56 O56O  Doctor Lee will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251266 - make referral to Doctor Stewart at General Surgery VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251267 - in San Francisco for consideration of "redo" fundaplicaiton.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251268 - ref SDS 56 JQ5J  Doctor Lee completed Progress Notes for EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251269 - on 141107. ref SDS 56 PS53  Doctor Lee will recommend Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251270 - order CT test to evaluate recurrance achalasia due to failure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251271 - fundoplication. ref SDS 56 TH5M  This test can include coronary CTA to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251272 - evaluate regression atherosclerosis. ref SDS 56 GB56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251274 -  ..
251275 - On 150420 1752 submitted letter to Doctor Lee with agenda for meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251276 - the next day on 150421 1300 for EGD dilation. ref SDS 57 0M6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251278 -  ..
251279 - On 150421 Met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251280 - (Mather). ref SDS 58 K37G  No difficulties setting IV for conscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251281 - sedation. ref SDS 58 5W5I  Reported pain level 2 right knee MCL.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251282 - ref SDS 58 LO9K  Doctor Lee advised referral to San Francisco will be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251283 - filed after EDG dilation procedure (this day) to evaluate loosening                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251284 - fundoplication. ref SDS 58 DZ4I  Patient reported difficulty                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251285 - swallowing this cycle did not occur until 4 weeks or so, because                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251286 - triamcinalone steriod was injected during prior procedure on 141107,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251287 - ref SDS 58 P55L, and shown by EGD dilation LESV from 16.5 mm back to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251288 - 18 mm. ref SDS 58 HU42  Progress Notes report findings of hiatal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251289 - hernia. ref SDS 58 QD6O  Impression today that ulceration has subsided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251290 - to mere errosions seems promising. ref SDS 58 PXXY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251292 -  ..
251293 - On 150514 0130 letter to Doctor Lee requests file Progress Notes for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251294 - EGD Dilation today, and make referral to Doctor Stewart, to prepare                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251295 - for meeting with Doctor Lee scheduled on 150521. ref SDS 60 K37G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251297 -  ..
251298 - On 150521 0800 meeting with Doctor Lee at VAMC in Sacramento -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251299 - concensus uncharacteristic vomitting after recent EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251300 - procedure on 150421, due to patient not eating slowly with small bites                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251301 - and drinking liquids frequently, especially when eating meat products                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251302 - that have high viscocity with esophageal tissue, and so tends to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251303 - stick, causing vomitting. ref SDS 61 WT9L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251305 -  ..
251306 - On 150526 1300 meeting with Doctor Stewart Chief General Surgery VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251307 - Medical Center San Francisco, review record indicating ulceration LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251308 - caused by reflux backwash into esophagus. ref SDS 62 3E4I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251309 - Stewart explained redo Dor Fundoplication required for "repairing"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251310 - original surgery, presents high risk of collateral damage. ref SDS 62                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251311 - GT5G  Considered increase dose Omeprazole (PPI) since ad hoc                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251312 - experience occasionally taking 3 and sometimes 4 pills instead of only                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251313 - 1 pill per day seemed to reduce reflux based on examination showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251314 - ulceration of LESV declined; this would avoid need to redo Dor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251315 - Fundoplication. ref SDS 62 5Y4I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251317 -  ..
251318 - On 150616 1624 received photographs on CD in word.docx file from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251319 - Phillip in ROI Department at VA MC in Sacramento (Mather) showing Dor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251320 - fundoplication in tact on 131115, beginning to unravel on 140507,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251321 - further unraveled on 141107, and unraveled on 150421. ref SDS 63 XW6M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251323 -  ..
251324 - On 150623 1300 during follow up meeting, Doctor Stewart discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251325 - again increasing Omeprazole PPI to resolve ulceration of LESV rather                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251326 - than risk difficult surgery to redo Dor fundoplication, and she                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251327 - ordered prescription for H2 blocker to supplement Omeprazole PPI.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251328 - ref SDS 64 WW5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251330 -  ..
251331 - On 150624 0924 letter notified Doctor Lee of work plan to try                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251332 - controlling ulceration of LESV by increasing PPI with Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251333 - rather than chance performing high risk surgery to repair Dor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251334 - fundoplication, and that Doctor Stewart ordered H2 Blocker for Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251335 - Lee to consider supplementing PPI to control acid reflux. ref SDS 65                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251336 - OP91                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251338 -  ..
251339 - On 150624 0924 at 1344 Doctor Lee called and will order new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251340 - prescription for PPI increasing Omeprazole from 20 mg twice per day to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251341 - 40 mg twice per day. ref SDS 65 L861                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251343 -  ..
251344 - On 150925 0336 request switch back to Omeprazole 20 mg twice per day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251345 - in order to reduce severe side effects of dehydration from frequent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251346 - urination causing scaling, peeling, bleeding feet; lower dose                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
251347 - Omeprazole enables hiking to raise HDL required to regress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251348 - atherosclerosis plaques, thereby lowering risks of CVD and CAD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251349 - ref SDS 66 5G8T  As a result, Pharmacy VA Medical Center San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251350 - entered new prescription for (PPI) Omeprazole 20 mg. ref SDS 66 FK66                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251352 -  ..
251353 - On 150925 0336 VA scheduled next meeting for EGD dilation on 151204                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251354 - 0800. ref SDS 66 SR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251356 -  ..
251357 - On 151002 1820 Doctor Lee returned call; will order Omeprazole 20 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251358 - prescription sufficient until next EGD Dilation procedure on 151204,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251359 - and complimenting prescription entered on 150925 for only 1 month.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251360 - ref SDS 67 NV5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251362 -  ..
251363 - On 151012 1151 VA Internet Pharmacy lists updated Omeprazole 20 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251364 - prescription. ref SDS 59 0C5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251366 -  ..
251367 - On 151204 0800 met with Doctor Lee at VA Medical Center in Sacramento                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251368 - (Mather); initial administration went well. ref SDS 68 GD4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251369 - Preparation for the procedure was professional; no difficulties                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251370 - setting IV for conscious sedation today. ref SDS 68 544G  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251371 - reported not receiving letter with agenda for the meeting today,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251372 - submitted on 151201. ref SDS 68 VV6N  Patient difficulty swallowing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251373 - occurred after 5 months, because triamcinalone steriod injected prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251374 - procedure on 150421.  Swallowing difficulty/vomiting increased over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251375 - the next 3 months indicates dilate LESV 18 mm and doing EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251376 - in 6 rather than 8 months. ref SDS 68 P55L  Asked about Baking Soda to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251377 - clear throat in order to avoid vomitting, and prevent ulceration LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251378 - alternative to Omeprazole in order to avoid side effects causing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251379 - dehydration. ref SDS 68 G53K  Performing EGD dilation procedure went                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251380 - smoothly, with no difficulties. ref SDS 68 7V6I  Post procedure Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251381 - Lee reported LESV contracted to 10 mm, the worst results in patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251382 - history, indicating 2 month delay performing procedure this cycle was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251383 - harmful. ref SDS 68 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251385 -  ..
251386 - On 151210 meeting Doctor Lee after EGD on 151204, changed prescription                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251387 - of Omeprazole (PPI) to 20 mg every other day to eliminate or reduce                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251388 - dehydration from frequent urination, and in order for feet to recover                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251389 - from peeling, cracking, bleeding so that hiking can be performed at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251390 - level of 300 miles per month required to raise HDL > 60, required to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251391 - regress athersclerosis. ref SDS 69 J56O  Doctor prescribed adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251392 - Famotidine an H2 blocker taken once a day to compliment Omeprazole.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251393 - ref SDS 69 YL3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251395 -  ..
251396 - On 160325 0900 Diffuculty swallowing this cycle began about 1 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251397 - after prior EGD dilation on 151204. ref SDS 71 P55L  Reported using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
251398 - baking soda to relieve reflux that prevents ulceration LESV; this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251399 - reduced Omeprazole in order to avoid dehydration. ref SDS 71 Z84H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251400 - Progress Notes report there is no longer any erosive esophagitis and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251401 - there is no evidence of mass effect, which implies better acid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251402 - suppression compared to previous examination December 2015.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251403 - ref SDS 71 PXXY  EGD dilation procedure went smoothly, with no reports                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
251404 - of difficulties. ref SDS 71 7V6I  Post procedure Doctor Lee reported                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
251405 - LESV contracted to 9.5 mm, the smallest in patient history, indicating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251406 - 2 month delay to 8 months performing procedure in December causing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251407 - continual injury. ref SDS 71 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
251409 -  ..
251410 - On 161128 1119 called VA GI Clinic in Sacramento; LaPreia said meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
251411 - Doctor Lee scheduled for 161214, has been changed to the next day on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251412 - 161215 1200. ref SDS 79 OZ9G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
251414 -  ..
251415 - On 161205 0846 anonomous flowers and chocolates sent wishing GI staff                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251416 - Merry Christmas and Happy New Year for doing terrific work.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
251417 - ref SDS 81 FS5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251419 -  ..
251420 - On 180417 0800 at 1120 Doctor Lee reported he was able to dilate LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
251421 - to 19 MM, the most ever. ref SDS 95 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251423 -  ..
251424 - On 180425 1130 Kathy met with Jessica and at that time Jessica                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
251425 - scheduled next EGD on 180605 0800, she scheduled review meeting 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251426 - weeks later on 180711, the next EGD dilation was scheduled 2 days                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251427 - later on 180713, and review meeting was scheduled 6 days later on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
251428 - 180719.   The review meeting ordered by Doctor Lee for 3 weeks after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
251429 - recent EGD on 180417, is still not scheduled. ref SDS 96 9O6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251431 -  ..
251432 - On 180924 0900 meeting with Doctor Summana Jothi at VA Clinic in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251433 - Martinez, determined larynx has slight opening, not enough to cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
251434 - occasinoal pronounced scratchy voice.  Reported caused by saliva                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
251435 - becoming backed up, because cannot go through LESV ref SDS A2 OL5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
251436 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251437 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251438 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251439 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251440 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
251442 -  ..
2515 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2516 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2517 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2519 -    ..
2520 -    ..
2521 -    ..
2522 -    ..
2523 -    ..
2524 -    ..
252401 - Esophagogastroduodenoscopy (EGD) and Dilation LESV Administration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252402 - GI Department VA Sacramento Medical Center Administration EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252403 - 
252404 - Follow up ref SDS C7 NU8L, ref SDS C2 NU8L.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252406 - EGD treatment with Doctor Lee today, was scheduled by Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252407 - 200529 0930. ref SDS C7 XF6X  Colonoscopy was planned in meetings with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252408 - GI team at VAMCSF on 200612 0700. ref SDS D1 LS5F  Letter to Gracie                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252409 - notified GI Clinic at VAMC in Sacramento, also reported on 200612                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252410 - 0700, ref SDS D1 HD68  On 200615 0902 letter referencing Gracie's                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252411 - letter on contacting Jessica about scheduling prep for colonoscopy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252412 - ref SDS D3 NE9N  Jessica sent letter with instructions on preparing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252413 - for colonoscopy, reported on 200615 0902. ref SDS D3 NJ7L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252415 -  ..
252416 - Currently, Doctor Lee has been doing EGD procedures every 8 weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252417 - The EGD scheduled on 200505, was cancelled due to risk of spreading                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252418 - coronavirus. ref SDS C4 NU8L  Schedule was updated by Jessica                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252419 - extending procedures to Jan of next year, reported on 200110 0830.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252420 - ref SDS C1 W44N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252422 -  ..
252423 - Applied EGD pre-proc requirements for NPO after midnight, from letter                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252424 - on 101015 1547. ref SDS 28 4J9L  Last food was at......                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252425 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252426 -                         207005 1730                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
252428 -  ..
252429 - Yesterday, drove to Sacramento from Concord on Monday, and stayed at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
252430 - Kathy's house about 3 miles from VAMC Sacramento.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
252432 -  ..
252433 - Colonoscopy pre-proc prcedures began taking 3 Bisacodyl 5mg tablets on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252434 - 200706 0800. ref SDS D5 4G4N   Took remaining 3 tablets the next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252435 - morning on 200706 0800. ref SDS D5 4G4N  Drank half-gallon Golytely on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
252436 - 200706 1800. ref SDS D6 3X5H  Drank 2nd half-gallon this morning,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252437 - reported on 200707 0400. ref SDS D7 4G4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252438 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252439 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252440 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252441 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252443 -  ..
2525 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2526 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2527 - 0850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2528 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
252801 - Arrived at VAMC Sacramento.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
252803 -  ..
252804 - Shanty did check-in to GI Department at the customer counter.  She was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252805 - as usual enthusiastic and helpful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252807 -  ..
252808 - Connie did vitals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
252810 -  ..
252811 - Vitals were taken today, and found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
252812 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252813 -            Weight.................. 181                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
252814 -            BP...................... 112 58                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
252815 -            HR (pulse).............. 92                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252816 -            Oxygen.................. 97                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
252817 -            Temp.................... 96.7                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
252818 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252820 -  ..
252821 - Kathy cell phone for designated driver...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
252825 -  ..
252826 - Kathy signed the discharge form affirming she will be designated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252827 - driver, and responsible to facilitate no driving for 24 hours.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
252829 -  ..
252830 - Went from vitals into prep room.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
252831 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252832 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252833 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252834 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
252836 -  ..
2529 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2531 - 0915                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2532 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253201 - Pre-op Preparation No Problems Getting Blood Flow for Anesthesia IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253202 - 
253203 - Follow up ref SDS C7 EP75, ref SDS C2 EP75.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253204 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253205 - No objections nor concerns today, as occurred previously on 161115                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253206 - 0800, ref SDS 77 WA5I, and again on 161130 1038. ref SDS 80 EP75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253208 -  ..
253209 - Saw Jennifer to say hello today.  She was kind remembering me.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253211 -  ..
253212 - Did not see Clair today, to say hello.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253214 -  ..
253215 - In the GI Clinic, Gracie directed me to a gurney.  She helped with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253216 - patient gown and setup on the gurney.  Saw Danis and said hello,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253217 - mentioning returned her call yesterday about the meeting this morning.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253219 -  ..
253220 - Grace entered patient history in the computer.  Most information                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253221 - entered today, for patient identification and medical history is the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253222 - same.  Grace entered recent changes:  left atrial ablation procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253223 - to end atrial fibrillation, reported on 200430 0700. ref SDS C3 IW9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253224 - Second ablation in the right atrial was done a few weeks ago on 200511                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253225 - 0546. ref SDS C5 244I  Patient now taking Clopidogrel, Apixaban blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253226 - thinner and Metoprolol to slow heart rate, also reported on 200103                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253227 - 0700. ref SDS B9 1X30  Clopidogrel and Apixaban were stopped 2 days                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253228 - ago on 200527, shown in case study on 200101 0702. ref SDS B8 N19H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253229 - Also paused Metoprolol this morning, ref SDS B8 T47G, IAW letter to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253230 - Doctor Simpson submitted on 200109 2121. ref SDS C0 WG9R  Was ordered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253231 - to Urgent care at VAMCSF for EKG and labs on 200611 0730. ref SDS C8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253232 - HI7L   Was sent to ER for CT and initial work up which found inflammed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253233 - colon.  Lab found WBC 17 and fever temperature 100.1, so admitted to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253234 - hospital reported on 200611 1105. ref SDS C9 QM73  Next day medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253235 - team diagnosed ischemic colitis, reported on 200612 0700. ref SDS D1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253236 - LY3G  Team ordered colonoscopy to complete workup on ischemic colitis,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253237 - reported on 200613 0519. ref SDS D2 W66K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253239 -  ..
253240 - Grace asked about pain?  Reported level 0.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253242 -  ..
253243 - Gracie set catheter IV for sedation.  She asked for best location to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253244 - get a good vein.  Explained inner right elbow right side vein worked                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253245 - well on 1st stick for prior EGD on 200529 0930. ref SDS C7 JA4N  Did                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253246 - not do 10 pushups with feet on gurney to improve blood flow.  Veins                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253247 - develop adhesions (scar tissue) that take time to heal, and prevent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253248 - blood flow into the IV needle.  This morning ran hot water on right                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253249 - forearm in the shower to dilate veins, which helped to get blood flow                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253250 - on 1 stick today.  Gracie used this location at inner right side of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253251 - elbow.  This was pain level 3.  It was successful.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253253 -  ..
253254 - Case study on sticks required to set catheter is reported on 110429                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253255 - 1230. ref SDS 33 UO3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253257 -  ..
253258 - Visited with Rachel Hall.  She has been hiking a lot lately, and is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253259 - interested in doing Half Dome with her boy friend on 200918.  Will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253260 - coordinate with email on finalizing.  Her email...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253261 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253262 -               hallrachellynn@gmail.com                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253264 -             ..
253265 -            [On 200709 1431 letter to Rachel bounced back, because used                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
253266 -            wrong email address; may explain why she did't get the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253267 -            letter on 200117. ref SDS D8 P45I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253269 -             ..
253270 -            [On 200709 1518 letter asking Ross if he is still                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253271 -            considering doing Half Dome in September, and letting him                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253272 -            know Rachel asked about using 2 of the permits. ref SDS D9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253273 -            5U92                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253275 -             ..
253276 -            [On 200710 0947 letter from Ross saying to let Rachel and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
253277 -            her friend do Half Dome; open to meeting in Yosemite or Bay                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253278 -            Area for family visit. ref SDS D0 MO85                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253280 -  ..
253281 - Rachel asked about history of HDL in relation to hiking.  This is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253282 - shown in spreadsheet...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253283 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253284 -              F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253285 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253286 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253287 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253288 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253289 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253290 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253292 -  ..
2533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2535 - 0932                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2536 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253601 - Meeting Doctor Lee and Consent for Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253602 - 
253603 - Follow up ref SDS C7 GG6G, ref SDS C2 GG6G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253605 -  ..
253606 - Doctor Lee asked questions on patient history to verify ready for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253607 - procedure, e.g., no allergies, and NPO after midnight to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253608 - conflicts with anesthesia; no health problems, e.g., no diabetes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253609 - alcohol, cigarettes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253611 -  ..
253612 - Doctor Lee asked about medication protocol?  Reported protocol he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253613 - prescribed after EGD on 190416 1000, ref SDS B0 JK6N, modified                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253614 - recently adding Apixaban and Metoprolol to treat paroxysml atrial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253615 - afibrillation, reported on 200103 0700. ref SDS B9 VT9J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253617 -  ..
253618 - This morning he confirmed the following prescription...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253619 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253620 -        Famotidine................0700.... 2 40mg pills in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253621 -        Metoprolol................0700.... 1 25 mg pill in morning taken with PPI and food                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253622 -        Clopedigrel...............0700.... 1 75 mg pill in morning taken with PPI and food                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
253623 -        Apixaban..................0700.... 1 05 mg pill in morning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253625 -         ..
253626 -        Hiking - most everyday taken an hour before start hikes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253627 -        Naproxen.......................... 2 200 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253628 -        Gabapentin........................ 1 300 mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253629 -        Glucosamine Chondroitin...........    80 ml                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253630 -        Oxycodone......................... sometimes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253631 -        Tramadol.......................... sometimes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253632 -        Nitroglycerin  (prescribed, but not likely to be taken)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253634 -         ..
253635 -        Pantoprazole..............1700.... 1 40mg pill 30 min before dinner every day                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253636 -        Atorvastatin..............1830.... 1 10mg pill every other day hour after dinner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253637 -        Ezetimibe.................1830.... 1 10mg pill every other day hour after dinner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253638 -        Mylanta...................2000.... 40 ml OA 2000 - 1 hour after statins                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253639 -        Calcium Carb (Tums).......2030.... 2 500mg pills 30 min after Mylanta                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
253640 -        Famotidine................2200.... 2 40mg pills before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253641 -        Apixaban..................2200.... 1 05 mg pill before bed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253642 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253643 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253644 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253646 -  ..
253647 - Paroxysmal Atrial Fibrillation Treated Ablation Pulmonary Vein Isolation on 200430                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253648 - Right Atrial Flutter Treated Ablation on 200511                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253649 - Vision Diminished Fatigue Sleepy Taking Metoprolol Treatment PAF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253650 - 
253651 - Follow up ref SDS C7 XN5F, ref SDS C2 XN5F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253652 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253653 - On 200430 0700 left atrial ablation performed by Doctor Pellegrini.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253654 - ref SDS C3 9C9M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253656 -  ..
253657 - On 200511 0546 at 1342 went to ASU for preparation to do ablation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253658 - ref SDS C5 244I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253660 -  ..
253661 - On 200527 0930 telecon meeting with Doctor Pellegrini advised ablation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253662 - procedures successfully treated atrial fibrillation and atrial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253663 - flutter. ref SDS C6 JJ6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253664 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253665 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253666 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253667 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253668 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253670 -  ..
253671 - Swallowing Has Been Effective Past 6 Weeks                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253672 - 
253673 - Follow up ref SDS C7 VV6N, ref SDS C2 VV6N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253675 -  ..
253676 - Eating regimen is shown in case study of daily diet, medication,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
253677 - exercise and vitals, reported on 200101 0702. ref SDS B8 UVXU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253679 -  ..
253680 - Reviewed eating practice - small bites taken with liquid, and mixing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
253681 - meat products with other food enables each bite to slip past small                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253682 - opening of LESV until next EGD dilates again.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
253684 -  ..
253685 - Doctor Lee glanced through case study on 190101 showing exercise,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253686 - diet, medication and vitals.  He feels record on typical diet and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253687 - eating for example on 191118, aligns with requirments for effective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253688 - swallowing under achalasia, ref SDS A7 VQUY; and on 191221.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
253689 - ref SDS A7 QVPV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
253691 -  ..
253692 - Bubbles clogging LESV seem reduced this cycle, especially past few                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253693 - weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
253695 -  ..
253696 - Burping seems better controlled compared to years past.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253697 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253698 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253699 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253701 -  ..
253702 - Digestion Deficit Woke Up Choking Aspirated Reflux                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
253703 - 
253704 - Follow up ref SDS C7 N27F, ref SDS C2 N27F.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253705 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253706 - No aspiration issues this past cycle, since Doctor Lee ordered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
253707 - increased Mylanta on 190618 0730. ref SDS B2 8468                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
253709 -  ..
253710 - This was recently increased again in the telecon meeting on 200625                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
253711 - 0800. ref SDS D4 T86J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
253712 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253713 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253714 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
253716 -  ..
2538 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2539 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2540 - 0947                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2541 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254101 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254102 - Consent Signed EGD Dilation and Meeting Review Pending Issues                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254103 - Consultation Pending Issues and Sign Consent for EGD Dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254104 - 
254105 - Follow up ref SDS C7 KT9M, ref SDS C2 KT9G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254107 -  ..
254108 - Doctor Lee presented a digital tablet and requested signature to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254109 - consent for the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254111 -  ..
254112 - Noted that signature is entered on completely black screen, required                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254113 - without reading online documents.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254115 -  ..
254116 - Advised that signature is based on following understandings...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254117 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254118 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254119 -    1.  Ischemic colitis - consider follow up CT evaluate for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254120 -        inflammation of left side intestine (colon), found during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254121 -        examination in ER at VAMCSF on 200611 1400. ref SDS D0 NH6J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254122 -        There was stomach pain during hike yesterday, after running to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254123 -        make traffic light, reported in case study on 200101 0702.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254124 -        ref SDS B8 WPQV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254125 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254127 -         ..
254128 -    2.  Stomach pain level 1 suddenly this morning at 0824; took                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254129 -        simethicone.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254130 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254132 -         ..
254133 -    3.  GoLYTELY may cause irregular heartbeats. seizures ? ulcers of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254134 -        the bowel or bowel problems (ischemic colitis). Tell your                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254135 -        healthcare provider right away if you have severe stomach-area                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254136 -        (abdomen) pain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254137 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254138 -              https://www.fda.gov/files/drugs/published/GoLytely-Medication-Guide.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254139 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254141 -         ..
254142 -    4.  Golytely - did not get version with pinapple taste - it was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254143 -        more like lima beans.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254144 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254146 -         ..
254147 -    5.  Frequent urination taking Pantaprazole everyday seems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254148 -        stabalized over the past treatment cycle, at rate that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254149 -        minimizes dehydration, shown on 200101 0701. ref SDS B7 PVTP                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254150 -        Occasionally, there will be nights getting up 4 - 6 times,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254151 -        e.g., on 191113 and 191113, ref SDS B7 J99F; however this is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254152 -        not persistent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254154 -         ..
254155 -    6.  Voice continues scratchy about the same following examination                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254156 -        and recommendations by Doctor Lee during prior EGD procedure on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254157 -        190917 0730. ref SDS B5 HE9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254159 -         ..
254160 -        Voice worse past few weeks, even when concentrating on washing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254161 -        throat with carbonated beverage after each bite of food during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254162 -        meals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254164 -         ..
254165 -        Voice overall better after recent increase dilating LESV to 20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254166 -        mm has improved swallowing, compared to prior practice dilating                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254167 -        to only 18 mm.  This has also improved voice function.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254169 -  ..
254170 - Asked Gracie about my voice today.  She said voice seems little                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254171 - scratchy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254173 -  ..
254174 - Doctor Lee concurred voice diminished worse this morning, as it has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254175 - been in the past.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254176 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254177 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254179 -         ..
254180 -    7.  Fundoplication failing, causing continual stricture of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254181 -        requiring frequent dilation.  Doctor planned to research this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254182 -        issue during meeting on 171115 1142. ref SDS 90 XA4F  Discussed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254183 -        again during meeting on 180124 1130. ref SDS 93 CT56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254185 -         ..
254186 -        On 180627 1300 Doctor Patel seemed to say GI Clinic at VAMCSF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254187 -        has investigated viability of gastroscope fundoplication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254188 -        procedures.  He seemed to further advise that the clinic has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254189 -        referred patients for gastroscope full fundoplication, but not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254190 -        to repair fundoplication. ref SDS 98 JX9F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254192 -         ..
254193 -        We reviewed the record in this case that Doctor Stewart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254194 -        performed Dor fundoplication on on 091216, as shown Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254195 -        Notes received on 100928 0706. ref SDS 26 VK8F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254197 -         ..
254198 -        At tht time on 180627 1300 asked Doctor Patel to review with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254199 -        the GI team prospects to repair Dor Fundoplication in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254200 -        reduced reflux that continually causes stricture that closes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254201 -        down LESV, requiring repeated EGD dilations on close intervals.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254202 -        ref SDS 98 HP4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254204 -         ..
254205 -        Discuss with Samantha Southi developing proposal for using                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254206 -        gastroscope to reposition Dor fundoplication for enhanced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254207 -        reflux control.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254209 -  ..
254210 - Did not discuss today, because seem to be managing reflux well enough                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254211 - to minimize formation of stricutre, so that swallowing is not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254212 - impaired, thus avoiding vomiting.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254213 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254214 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254216 -         ..
254217 -    8.  Hiatal Hernia - can this subside or otherwise improve over                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254218 -        time with any action by patient, similar to ulceration of LESV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254219 -        recovering by ending naproxen, and adding carbonated beverage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254220 -        to washout esophagus during meals?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254222 -         ..
254223 -        What drives worsening of hiatal hernia?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254225 -  ..
254226 - Did not discuss this today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254227 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254228 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254230 -         ..
254231 -    9.  Dilation 19 - 20 mm                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254233 -         ..
254234 -        Assess today, toward maintaining reduced medication dose, or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254235 -        increase dose on findings of ulceration LESV recurrance.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254237 -  ..
254238 - Today, Doctor Lee dilated LESV from 19/20 to 20 mm, reported in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254239 - Progress Notes shown below. ref SDS B6 X95J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254240 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254241 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254243 -         ..
254244 -   10.  Conscious Sedation with versed - asked Doctor Lee to limit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254245 -        injection of versed to 4 mg, if feasible - possibly 2 for EGD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254246 -        and 2 for colonoscopy.  In no case do not exceed 5 mg, in order                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254247 -        to avoid stroke symptoms on 160617 1637, ref SDS 73 5F6F,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254248 -        following EGD earlier that day when procedure took 30 minutes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254249 -        100% longer, and so versed was increased to 6 mg, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254250 -        160617 0800, ref SDS 72 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254252 -  ..
254253 - This was discussed with Doctor Lee.  He expects both EGD and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254254 - colonoscopy can be completed with 4 mg versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254255 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254256 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254257 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254258 -   11.  Barium Swallow Test                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254260 -  ..
254261 - Did not discuss.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254262 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254263 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254264 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254265 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254267 -  ..
254268 - OR EGD Dilation with Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254269 - EGD Dilation Procedure in OR Application Lidocaine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254270 - 
254271 - Follow up ref SDS C7 HE9I, ref SDS C2 HE9I.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254272 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2545 - 1004                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254601 -  ..
254602 - Katie is nurse in the room today, and dressed in patient protection                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254603 - equipment to avoid spread of coronavirus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254605 -  ..
254606 - Katie set blood pressure cuff and EKG probes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254608 -  ..
254609 - Katie connected sensors to monitor vitals.  She connected IV to saline                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254610 - drip, ready to apply conscious sedation drugs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254612 -  ..
254613 - EKG showed sinus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254615 -  ..
254616 - Everything went smoothly in the OR today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254618 -  ..
254619 - Katie squirted lidocaine in the mouth, and said to gargle for 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254620 - seconds.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254622 -  ..
254623 - After placing a bite block, Katie covered the face with a plastic cup                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254624 - connected to oxygen.  This is a new type of equipment to reduce                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254625 - exposure to infectious virus, in this case coronavirus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254627 -  ..
254628 - Katie applied versed for conscious sedation using the catheter, which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254629 - Gracie set earlier in Preparation, per above. ref SDS 0 JA4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
254630 - Understandings were applied on sedation protocol reviewed with Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254631 - Lee and agreed in signing the consent, per above. ref SDS 0 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254633 -  ..
254634 - Dontay was the technician.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254636 -  ..
254637 - The team then did the EDG/dilation procedure with Doctor Lee.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254639 -  ..
254640 - Gastroscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254641 - Procedure 1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254642 - Start Time........... 1015                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254643 - Procedure Stop....... 1026                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254645 -  ..
254646 - Time for 1st procedure...... 11 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254648 -  ..
254649 - Procedure 1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254650 - Start Time........... 1051                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254651 - Procedure Stop....... 1100                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254653 -  ..
254654 - Time for 2nd procedure......  9 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254656 -  ..
254657 - Total time.................. 20 minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254658 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254660 -  ..
254661 - Nursing Procedural Sedation & Analgesia Flow Sheet Record - Page 1 of 2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254662 - Versed total................   4 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254663 - Fentanyl total.............. 200 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254664 - Benadryl....................  50 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254665 - Lidocaine...................  10 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254666 - IV Fluids normal saline.....     ML  no report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254667 - Triamcinalone...............   0 ML                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254669 -  ..
254670 - During procedure while asleep...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254672 -  ..
254673 - Blood pressure 135/86 to 117/72  Heart Rate 78 - 64                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254674 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254675 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254677 -  ..
254678 - Nurses note says patient feeling anxious; has minor cut on upper lip.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254680 -  ..
254681 - EKG shows patient in sinus...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254682 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254683 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254684 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254685 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254686 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254688 -  ..
254689 - LESV Contact 1 MM Dilation 20 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254690 - Meeting Doctor Lee EGD Dilation 20 MM Ulceration Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254691 - Ulceration Resolved Meeting Doctor Lee EGD Dilation 20 MM                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254692 - 
254693 - Follow up ref SDS C7 5H5J, ref SDS C2 5H5J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254694 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254696 -  ..
2547 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2548 - 1135                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2549 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254901 - Woke in recovery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254903 -  ..
254904 - Post Procedure Care Record...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254906 -  ..
254907 - Blood pressure 112/62 to 123/65  Heart Rate 58 - 69                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254908 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254909 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254910 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254912 -  ..
254913 - Doctor Lee arrived.  He reported good results again today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254915 -  ..
254916 - LESV contracted only 1 mm from 20 back to 19 mm, showing continuing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254917 - improvement compared to severe weekly contractions evident from case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254918 - study below. ref SDS 0 XM3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
254920 -  ..
254921 - There was a slight tissue errosion along a small point at LESV.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254922 - thinks a pill possibly somehow got stuck and irritated the tissue,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254923 - causing minimal errosion, but no ulceration.  Indicated this has no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254924 - medical siginficance.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254926 -  ..
254927 - Doctor Lee explained dilating the baloon from 19 mm to 20 mm.  There                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254928 - was slight bleeding, but no actual breaks in LESV tissue.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
254930 -  ..
254931 - Versed was limited today, to 2 ml, as discussed during the meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
254932 - before the procedure, per above. ref SDS 0 639M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254934 -  ..
254935 - The doctor indicated current medication and eating regimens, per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254936 - above, ref SDS C7 FV8H, should continue to maintain recovery from prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
254937 - achalasia difficulties, i.e., work today demonstrated strong response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254938 - to treatment recovering from esophageal ulceration, including omitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254939 - Triamcinalone.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254940 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254941 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254943 -  ..
254944 - Colonoscopy Found 2 Sites of Ischemic Colitis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254945 - 
254946 - Doctor Lee explained the procedure today verified diagnosis of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254947 - ischemic colitis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
254949 -  ..
254950 - He found tissue errosion (see diagram  xxx) that aligned with CT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
254951 - test on 200611, showing inflammation on left side of colon.  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254952 - further found another tissue disruption on the right side, which may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254953 - have occurred since the CT.  Doctor Lee said he took 9 biopsies, as                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254954 - marked in the diagram he submitted...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254955 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254956 -    B = biopsy sites                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254957 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254958 -             ------------------------------------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254959 -            /         B                  B             \                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254960 -           /                                      x x   \                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254961 -           |      -------------------------------- x    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254962 -           |     /                                \     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254963 -           |    |            shallow errosion   /  |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254964 -           |    |                     ischemic /   |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254965 -           |    |                      colitis     |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254966 -           |    |                                  |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254967 -           |    |                                  |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254968 -           |    |                                  | B  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254969 -           |    |                                  |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254970 -  shallow errosion                                 |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254971 -  ischemic |x   |                                  |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254972 -   colitis |xx  |                                  |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254973 -           |x    ----                              |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254974 -           |     ----                             /     |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254975 -           |    |                -----------------      |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254976 -           |    |               /             B        /                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254977 -           |    |               /                     /                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254978 -           |    |              |      ---------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254979 -           |    |              |     /                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
254980 -           | B  |              |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254981 -           |    |              | B  |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254982 -                               |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254983 -                               |    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
254984 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254986 -  ..
254987 - Doctor Lee seemed to say stomach pain during hike yesterday, may be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
254988 - caused by dehydration during hikes over 3 hours in temperatures > 80.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254989 - The 14-mile hike yesterday was 4 hours and temperature was 83,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254990 - reported in case study on 200101 0702. ref SDS B8 FD4L  He indicated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
254991 - dehydration can be identified by dark colored urine.  Suggested                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254992 - increasing hydration during hikes on hot days.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
254993 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
254995 -             ..
254996 -            [On 200716 0800 received biopsy report and a letter from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
254997 -            Doctor Lee - he also called and said there was colitis at 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
254998 -            of the 6 biopsy sites. ref SDS E2 UC5L,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
254999 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255000 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255001 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255002 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255003 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255004 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
255005 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2551 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Achalasia Spreadsheet Correlate LESV Contractions PPI Triamcinalone                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2603 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260401 -  ..
260402 - EGD Chart Correlate Time Dilation Triamcinalone Sedation Drugs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260403 - 
260404 - Follow up ref SDS C7 XM3J, ref SDS C2 XM3J.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260405 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260406 - Today, was EGD #63                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260408 -  ..
260409 -                                                                  Bena                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260410 -                                                         Versed/  dryl                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260411 -                    ** MEDICATIONS LESV DILATE  Triamcin Midaz   Diphenhy  Fenta  Lido                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260412 -        Months          PPI FMTDN   from -  to    olone  olam    dramine    nyl   caine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260413 -      Interval  Date     mg   mg     mm     mm      mL     mg      mg       mg     mL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260414 -          1.25  200707   40  160     19     20......0.0.....2......50......100.....10.... ref SDS 0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260415 -          2.5   200529   40  160     19     20......0.0.....2......50......100.....10.... ref SDS C7 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260416 -          2     200310   40  160     19     20......0.0.....3......50......150.....10.... ref SDS C2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260417 -          2     200110   40  160     19     20......0.0.....3......50......150.....10.... ref SDS C1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260418 -          2     191112   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260419 -          1     190917   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260420 -          1     190813   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260421 -          1     190709   40  160     20     20......0.0.....3......50......150.....10.... ref SDS B3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260422 -          1     190618   40  160     19     20......0.0.....3......50......150.....10.... ref SDS B2 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260423 -          1     190521   40  160     18     20......0.0.....3......50......200.....10.... ref SDS B1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260424 -          1     190416   40  160     18     20....100.0.....3......50......200.....10.... ref SDS B0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260425 -          1     190319   40  160     19     20......0.0.....3......50......150.....10.... ref SDS A9 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260426 -          1     190215   40  160     19     20......0.0.....3......50......150.....10.... ref SDS A8 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260427 -          1     190118   40  160     18     20......0.0.....3......50......150.....10.... ref SDS A6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260428 -          1     181218   40  160     18     20......0.0.....4......50......150.....10.... ref SDS A6 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260429 -          1     181127   40  160     18     20......0.0.....3......25......250.....10.... ref SDS A5 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260430 -          1     181030   40  160     18     20......0.0.....3......25......250.....10.... ref SDS A4 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260431 -          1     181002   40  160     18     20......0.0.....3......25......250.....10.... ref SDS A3 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260432 -          1     180904   40  160     16.5   19......0.0.....3......25......250.....10.... ref SDS A1 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260433 -          1     180814   40  160     16     19......0.0.....3......25......250.....10.... ref SDS A0 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260434 -          0.5   180713   40  160     16.5   18......0.0.....3......25......250.....10.... ref SDS 99 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260435 -          2.5   180627   40  160     12     16.5....0.0.....3......25......250.....10.... ref SDS 97 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260436 -          2     180417   40  160     16.5   19......1.0.....3......25......250.....10.... ref SDS 95 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260437 -          1.50  180227   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS 94 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260438 -          1.25  180109   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS 92 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260439 -          1     171128   40  160     16.5   18......1.0.....4......25......250.....10.... ref SDS 91 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260440 -          2     171031   40  160     15.5   18......1.0.....4......25......250.....10.... ref SDS 89 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260441 -          1.53  170905   80   80     15     18......1.0.....3......25......250.....10.... ref SDS 88 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260442 -          1.53  170516   80   80     16.5   19......1.0.....5......25......250.....10.... ref SDS 87 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260443 -          1.53  170404   80   80     16.5   18......1.5.....5......25......200.....10.... ref SDS 86 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260444 -          1.53  170221   80   80     15     18......2.0.....5......25......200......5.... ref SDS 85 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260445 -          0.80  170106   80   80     16.5   18......2.0.....5......25......200......5.... ref SDS 84 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260446 -          0.23  161213   80   80     15     18......3.0.....5......25......200......5.... ref SDS 83 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260447 -          0.20  161206   80   80     11     16.5....1.0.....5......25......200......5.... ref SDS 82 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260448 -          0.27  161130   80   80     11     15......0.0.....5......25......200......5.... ref SDS 80 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260449 -          0.23  161122   80   80      6     12......0.0.....5......25......200......5.... ref SDS 78 433O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260450 -          1.40  161115   42   80     10     10......0.0.....5......25......200......5.... ref SDS 77 5H5J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260451 -          0.83  161004   26   80     11     15......5.0.....5......25......200......5.... ref SDS 76 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260452 -     *1   0.80  160909   80    0     10     15......5.0.....5......25......200......5.... ref SDS 75 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260453 -          2     160816   11   40      9.5   10......5.0.....4......50......150......5.... ref SDS 74 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260454 -          3     160617   10   40      9.5   15......5.0.....6......50......250......5.... ref SDS 72 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260455 -     *2   3     160315   15   40      9.5   15......3.0.....5......25......250......5.... ref SDS 71 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260456 -          8     151204   32   20     10     15......5.0.....5......25......200......5.... ref SDS 68 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260457 -     *3   6     150421   41          16.5   18......3.0.....4......50......250......5.... ref SDS 58 HU42                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260458 -          6     141107   37          15     18......4.0.....5......50......150......5.... ref SDS 55 E54M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260459 -          6     140509   24          16.5   18..............5......50......200......5.... ref SDS 49 P680                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260460 -     *4   7     131115   24          16.5   18......2.0.....4......50......200......5.... ref SDS 43 RZ45                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260461 -          3     130416   38          18     18......2.0.....5......50......250......5.... ref SDS 42 Y850                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260462 -          4     130110   39          15     18......3.0.....4......50......100......5.... ref SDS 41 Q333                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260463 -     *5   6     120925   38          15     18......4.0.....5......50......200......5.... ref SDS 40 XB51                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260464 -     *6   4     120322   27          16.5   18..............4......50......150......5.... ref SDS 39 516N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260465 -     *7   3     111115   76          16.5   18..............4......50......200......5.... ref SDS 36 IR57                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260466 -          4     110819   80          15     16.5....2.5.....5......50......200......5.... ref SDS 35 J978                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260467 -          2     110429   80          13     16.5....3.5.....5..............200......5.... ref SDS 32 U23I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260468 -          2     110218   80          11     14......2.0.....4......50......150......5.... ref SDS 31 AA5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260469 -          4     101210   40          11     14......................................5.... ref SDS 29 H347                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260470 -          6     100827    4          11     15..............5......50......250......5.... ref SDS 25 JE6X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260471 -          3     100305    0          11     15..............5......50......250......5.... ref SDS 24 WR6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260472 -          -     091216               Heller Myotomy Fundoplication................. ref SDS 22 KE9U                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260474 -         ..
260475 -     ** Dates are from case study on exercise, diet, vitals and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260476 -        medication, shown on 160101, ref SDS 70 0001, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260477 -        previously on 140101. ref SDS 46 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260478 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260479 -     *1 On 160911 paused Pantoprazole to reduce dehydration through                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260480 -        frequent urination until after Half Dome, and resumed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260481 -        160920.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260482 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260483 -     *2 On 151210 begin Omeprazole 20 mg every other day. ref SDS 46 E64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260484 -        Resumed Omeprazole 20 mg on 160323. ref SDS 70 RSXR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260486 -         ..
260487 -        On 150924 hospitalized hematoma debridement; begin Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260488 -        20 mg per day. ref SDS 46 JT4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260489 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260490 -     *3 On 150920 about 5 attacks convulsions, nausea not taking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260491 -        Omeprazole - took 40 mg. ref SDS 46 656M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260492 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260493 -     *4 On 131115 Doctor Lee prescribed Omeprazole 40 mg 1 month then                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260494 -        20 mg for next 5 months. ref SDS 43 ZY5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260496 -         ..
260497 -     *5 On 130106, 4 days before EGD on 130110, reduced Omeprazole to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260498 -        20 mg per day, shown in case study on 120101 0900, ref SDS 38                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260499 -        AD5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260500 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260501 -     *6 On 120907 Doctor Egan research found Omeprazole increases                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260502 -        blood pressure, sensed possible correlation patient sudden                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260503 -        rise in blood pressure, recommended reducing Omeprazole                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260504 -        to 20 mg per day.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260505 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260506 -     *7 On 11115 Doctor Lee prescribed continue PPM 80 mg; on 111201,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260507 -        patient reduced dose to 20 mg on record of rising blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260508 -        pressure despite increased hiking; research indicated PPI may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260509 -        elevate blood pressure, see case study 101010 0744, ref SDS 27 734L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260510 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260511 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260513 -  ..
260514 - Conscious Sedation Reduced Dose Applied for 12 Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260515 - 
260516 - Follow up ref SDS C7 714N, ref SDS C2 714N.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260517 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260518 - Nursing Procedural Sedation & Analgesia Flow Sheet Record Page 1 shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260519 - versed 2 ML.  Since procedure only took 12 minutes, ref SDS C7 Q65I,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260520 - the doctor was able to minimize exposure to versed, which previously                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260521 - caused stroke symptoms with 6 ml, as occurred on 160617 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260522 - ref SDS 72 P341                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260524 -               ..
260525 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260527 -  ..
260528 - No post procedure side effects as occurred previously on 161213 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260529 - ref SDS 83 R74J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260531 -  ..
260532 - Seem sleepy though even hours after the procedure using 3 ml versed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260533 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260534 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260536 -  ..
260537 - Ulceration on Esophagus Above LESV Significantly Resolved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260538 - 
260539 - Follow up ref SDS C7 RZ3G, ref SDS C2 RZ3G.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260540 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260541 - Doctor Lee reported this morning that EGD procedure found that both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260542 - ulcerations on the side of esophagus above LESV continue to be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260543 - completely resolved, reported following EGD on 190917 0730.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
260544 - ref SDS B5 RZ3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260546 -  ..
260547 - As a result, he omitted Triamcinalone again today, and maintained                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260548 - medication regimen taking Pantoprozole everyday - see case study                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260549 - above. ref SDS B6 YR4H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260551 -  ..
260552 - Doctor Lee did not have time to present pictures showing improved                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260553 - condition with reduced ulceration of LESV, following EGD dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260554 - procedure today, per above. ref SDS B6 GD5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260556 -  ..
260557 - Pictures from procedure were later received on 191209, and are at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260558 - bottom of the file...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260559 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260560 -              F:\05\00003\SM\CC\AGMJ\20191112-083000\WELCH12092019.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260562 -  ..
260563 - Decided to continue pentoprazole everyday before dinner for next 8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260564 - weeks.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
260565 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260566 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260568 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260570 -  ..
260571 - Schedule Next Procedure and Post Procedure Review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260572 - 
260573 - Follow up ref SDS C7 XF6X, ref SDS C2 XF6X.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260574 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260575 - Next procedure is scheduled on 200908 0930, ordered by Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
260576 - 200310 0830. ref SDS C2 W44N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
260578 -  ..
260579 - Since LESV seems to have contracted back to 19 mm during this 1.2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260580 - month cycle, Doctor Lee decided to continue schedule on 2 month                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260581 - cycles, and evaluate after each procedure possibly skipping a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260582 - scheduled procedure, if things go really well.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
260584 -  ..
260585 - Continuing schedule for EGD is...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260586 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260587 -        Sep 08 2020   0930   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260588 -        Nov 03 2020   0830   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260589 -        Jan 05 2020   0830   Sac GI procedure 5     Building 645  1st Floor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260591 -  ..
260592 - Need to ask the doctor about extending schedule through 2021.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
260594 -  ..
260595 - Called and talked to Dennis.  He scheduled telecon with Doctor Lee on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
260596 - 200716 0800.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
260597 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260598 -    1.  Ask about diagram he drew explaining findings from EGD and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
260599 -        colonoscopy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260600 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260601 -            [On 200716 0800 Doctor Lee called - he explained the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
260602 -            handwriting that seems to say "ovarian", actually was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
260603 -            intended to say errosion. ref SDS E1 OG3J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
260604 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260606 -         ..
260607 -    2.  Schedule follow up EGD for 2021.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
260608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260609 -            [On 200716 0800 Doctor Lee called - he will notify Jessica                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
260610 -            to schedule EGD procedures for rest of 2021. ref SDS E1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
260611 -            HH3N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260612 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260613 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260614 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
260616 -  ..
2607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
2609 - 1142                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
2610 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
261001 - Visited ROI.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
261002 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261003 - Talked to David.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
261005 -  ..
261006 - Submitted form requesting medical records including imaging and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261007 - pathology for EGD and colonoscopy performed today in GI Clinic.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261009 -  ..
261010 - Rquested CD mailed to home.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
261011 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261012 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261013 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261014 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261015 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261016 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
261017 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2611 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
2703 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270401 -  ..
270402 - Progress Notes Release of Information ROI CD Contents Received on 190316                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270403 - 
270404 - Follow up ref SDS C7 Q05K, ref SDS C2 Q05K.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270406 -  ..
270407 - After discharge from GI Clinic, Kathy and I walked to ROI in the main                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270408 - building of VA Medical Center.  Requested records on CD from ROI for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270409 - this medical encounter due to continual difficulties downloading                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270410 - medical records from VA website at...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270411 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270412 -              https://www.myhealth.va.gov/mhv-portal-web/track-health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270413 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270419 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270420 -            [On 200803 1418 received in the mail a CD with medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270421 -            records for EGD and colonoscopy performed at VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270422 -            Center in Sacramento on 200707. ref SDS E3 WS5M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270424 -  ..
270425 - Stored Progess Notes for procedure on 190813 at location...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270426 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270427 -              F:\05\00003\SM\CC\AGMJ\20200707-093000\welch_7-22-2020.pdf                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270429 -  ..
270430 - This file includes photographs taken during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270431 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270432 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270433 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270434 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270435 - ====================================================================                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270436 - EGD Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270437 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270438 -        Sacramento VA Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270439 -        10535 Hospital Way Mather CA, 95655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270441 -         ..
270442 -        EGD PROCEDURE REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270443 -        EXAM DATE: 07/07/2020                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270445 -         ..
270446 -        PATIENT NAME: Welch, Rodney C             MR#: 561720144                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270447 -        BIRTHDATE: 03/01/1945                     VISIT #: 3200707090627                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270448 -        ATTENDING: Randall Lee, MD                STATUS: outpatient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270449 -        ASSISTING MD:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270450 -        ASSISTANT: Katherine Slugocki, RN and Dontay Phillips, Tech                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270452 -         ..
270453 -        INDICATIONS: The patient is a 75 yr old male here for an EGD due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270454 -        PROCEDURE PERFORMED: EGD, screening                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270455 -        MEDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270456 -        TOPICAL ANESTHETIC:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270458 -         ..
270459 -        CONSENT:  The risks, benefits, and alternatives to this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270460 -        procedure including but not limited to the risks of bleeding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270461 -        and bowel perforation were explained to the patient.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270462 -        patient understood and provided written informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270464 -         ..
270465 -        DESCRIPTION OF PROCEDURE:  In the Sacramento VA GI Endoscopy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270466 -        Unit, Informed consent was verified, confirmed and timeout was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270467 -        performed. The patient was placed in left lateral decubitus                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270468 -        position. Oxygen was administered. Continuous oximetric and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270469 -        hemodynamic monitoring was initiated.  Intravenous sedation was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270470 -        administered in divided doses. After a bite block was placed in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270471 -        the patient's mouth, the gif-hq190-2858042 videoscope was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270472 -        introduced under direct vision through the mouth and advanced                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270473 -        to the .  The stomach and esophagus were decompressed, and the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270474 -        gastroscope removed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270475 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270477 -  ..
270478 - Photographs (12) of esophagus and stomach - images C01 - C12 - are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270479 - shown on page 1 of 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270481 -  ..
270482 - Photographs (8) of esophagus and stomach - images C13 - C20 - are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270483 - shown on page 2 of 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270485 -  ..
270486 - There are no evident comments on any pictures.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270487 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270488 -        ADVERSE EVENTS: There were no complications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270489 -        IMPRESSIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270490 -        RECOMMENDATIONS: EGD & dilation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270491 -                         achalasia & GERD stricture                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270493 -                          ..
270494 -                         See colonoscopy for total sedatives.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270495 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270496 -                         start 1015                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270497 -                         end 1026                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270499 -         ..
270500 -        FINDINGS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270501 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270502 -            1.  Proximal and mid esophageal body dilated and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270503 -                aperistaltic, with accumulation of saliva within the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270504 -                esophageal body that required irrigation and suctioning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270505 -                to achieve a clear view of the esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270507 -                 ..
270508 -            2.  Tattoo site in the esophageal body at about 31 cm again                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270509 -                noted without evidence of mass effect or ulceration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270511 -                 ..
270512 -            3.  Distal esophageal mucosal defects, shallow, at prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270513 -                sites of ulcerations.  Shallow erosion at GE junction.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270515 -                 ..
270516 -            4.  Esophageal stricture located at the GE junction at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270517 -                38-39 cm, estimated diameter of approximately 19 mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270518 -                TTS balloon dilated 18-19-20mm. Mucosal trauma only                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270519 -                after balloon dilation from 19-20mm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270521 -                 ..
270522 -            5.  Diaphragm located at 40 cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270524 -                 ..
270525 -            6.  Normal-appearing gastric mucosa in the fundus and body.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270526 -                Gastric fundus appearance consistent with known history                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270527 -                of fundoplication with relaxation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270529 -                 ..
270530 -            7.  Gastric mucosa in the antrum with patchy erythema but no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270531 -                ulceration, erosion, or mass effect.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270533 -                 ..
270534 -            8.  Normal pylorus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270536 -                 ..
270537 -            9.  Normal duodenum to D3.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270538 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270540 -         ..
270541 -        Impression                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270542 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270543 -            1.  minor reduction in GE junction lumen diameter since                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270544 -                last dilation of May 2020.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270545 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270546 -            2.  shallow distal esophageal erosion likely due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270547 -                medication in esophagus.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270549 -         ..
270550 -        Recommendations                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270551 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270552 -            1.  continue current anti-acid reflux therapies. reinforce                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270553 -                flushing of esophagus with liquid after medications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270554 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270555 -            2.  repeat EGD & dilation in about 2-3 months.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270556 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270558 -         ..
270559 -        REPEAT EXAM:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270560 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270562 -         ..
270563 -        Randall Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270564 -        PATIENT NAME: Welch, Rodney C                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270565 -        MR#: 561720144                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270566 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270567 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270568 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270569 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270570 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270571 - ====================================================================                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270572 - Colonoscopy Procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270573 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270574 -        LOCAL TITLE: Colonoscopy Procedure Report                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270575 -        STANDARD TITLE: GASTROENTEROLOGY DIAGNOSTIC STUDY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270576 -        DATE OF NOTE: JUL 07, 2020@12:30:39    ENTRY DATE: JUL 07, 2020@12:30:39                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270577 -        AUTHOR: CLINICAL,DEVICE PRO            EXP COSIGNER:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270578 -        URGENCY:                               STATUS: COMPLETED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270579 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270580 -        *** Colonoscopy Procedure Report Has ADDENDA ***                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270581 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270582 -        ** DOCUMENT IN VISTA IMAGING **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270583 -        SEE FULL REPORT IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270585 -         ..
270586 -        SIGNATURE NOT REQUIRED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270587 -        SEE SIGNATURE IN VISTA IMAGING                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270588 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270589 -        ** (PENTAX Colonoscopy) AUTO-INSTRUMENT DIAGNOSIS **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270591 -         ..
270592 -        Procedure: COL COLONOSCOPY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270594 -         ..
270595 -        PENTAX INSTRUMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270596 -        10535 Hospital Way Mather CA, 95655                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270598 -         ..
270599 -        COLONOSCOPY PROCEDURE REPORT      EXAM DATE: 07/07/2020                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270601 -         ..
270602 -        PATIENT NAME: Welch, Rodney C     MR #: 561720144                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270603 -        BIRTHDATE: 03/01/1945             VISIT #: 3200707091125                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270604 -        ENDOSCOPIST: Randall Lee, MD      STATUS: outpatient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270605 -        ASSISTING MD:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270606 -        ASSISTANT: Katherine Slugocki, RN and Dontay Phillips, Tech                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270608 -         ..
270609 -        INDICATIONS: The patient is a 75 yr old male here for a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270610 -        colonoscopy due to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270612 -         ..
270613 -        PROCEDURE PERFORMED: Colonoscopy, diagnostic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270614 -        MEDICATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270615 -        PREP TYPE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270616 -        PREP QUALITY:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270617 -        ESTIMATED BLOOD LOSS: None                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270619 -         ..
270620 -        CONSENT:  The risks, benefits, and alternatives to this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270621 -        procedure including but not limited to the risks of bleeding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270622 -        and bowel perforation were explained to the patient.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270623 -        patient understood and provided written Informed consent.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270625 -         ..
270626 -        DESCRIPTION OF PROCEDURE:  In the Sacramento VA GI Endoscopy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270627 -        Unit, consent was verified and timeout was performed.  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270628 -        patient was placed in left lateral decubitus position.  Oxygen                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270629 -        was administered.  Continuous oximetric and hemodynamic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270630 -        monitoring was initiated.  Intravenous sedation was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270631 -        administered in divided doses.  A digital exam    After digital                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270632 -        rectal examination, an PCF-H190L-2839103 videoscope was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270633 -        advanced under direct vision from the anus to the     using the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270634 -        water exchange technique.     The colon was inflated with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270635 -        carbon dioxide and a retroflexed view in the rectum was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270636 -        performed. The colon was decompressed and the colonoscope                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270637 -        removed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270639 -         ..
270640 -        COLON FINDINGS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270641 -        SCOPE WITHDRAWAL TIME:            Minutes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270642 -        COMPLICATION: There were no complications.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270643 -        IMPRESSIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270645 -         ..
270646 -        RECOMMENDATIONS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270647 -        colonoscopy and ileoscopy with biopsy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270648 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270649 -        2010 colonoscopy: no polyps.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270650 -        2020 June: intermittent abdominal pain which worsened                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270651 -        significantly after he was hiking strenuously in high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270652 -        temperatures.  Admitted to the San Francisco VA between June 11                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270653 -        and June 13, 2020.  He had a leukocytosis and CT scan showed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270654 -        thickening of the colon wall around the splenic flexure,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270655 -        presumed ischemic colitis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270657 -         ..
270658 -        Yesterday had recurrence of abdominal pain while hiking 16                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270659 -        miles.  Takes naproxyn + gabapentin daily in lieu of platelet                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270660 -        injections.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270661 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270662 -        total for EGD and colonoscopy:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270663 -        versed 4mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270664 -        fentanyl 200mcg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270665 -        benadryl 50mg                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270666 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270667 -        water exchange + CO2                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270668 -        colon prep score 9/9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270669 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270670 -        start 1031                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270671 -        cecum 1035                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270672 -        end 1100                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270673 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270674 -        ileum normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270675 -        cecum normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270676 -        ascending colon: patches of erythema and ulceration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270677 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270678 -        transverse colon: normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270679 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270680 -        splenic flexure: patch of mucosal thickening, firmness,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270681 -        erythema, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270682 -        ulceration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270683 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270684 -        descending colon: normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270685 -        sigmoid colon: normal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270686 -        rectum: normal mucosa.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270687 -        anus: hemorrhoids.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270688 -        prostate: no nodules.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270690 -         ..
270691 -        Impression:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270692 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270693 -        1.  findings consistent with ischemic colitis, however                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270694 -            differential diagnosis of splenic flexure area includes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270695 -            infiltrating malignancy.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270697 -             ..
270698 -        2.  combination of dehydration, reduced cardiac output from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270699 -            recent ablations, naproxyn increases risk for ischemic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270700 -            colitis and for kidney damage.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270702 -         ..
270703 -        Recommend:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270704 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270705 -        1.  Await pathology.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270706 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270707 -        2.  Schedule rest and rehydration breaks during hikes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270708 -            monitor quantity and quality of urine as one indicator of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270709 -            need for rehydration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270710 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270711 -        3.  reduce use of naproxyn.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270713 -         ..
270714 -        RECALL:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270715 -        _____________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270716 -        Randall Lee, MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270717 -        eSigned: Randall Lee, MD 7/7/2020 12:30:29                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270718 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270719 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270720 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270721 - ====================================================================                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270722 - Colonoscopy Biopsies                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270723 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270724 -        SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270725 -        10535 HOSPITAL WAY MATHER, CA 95655-4200                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270727 -         ..
270728 -        As of: Jul 22, 2020@10:25                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270729 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270730 -        ---- SURGICAL PATHOLOGY ----                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270732 -         ..
270733 -        Reporting Lab: SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270734 -                       10535 HOSPITAL WAY MATHER, CA 95655-4200                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270736 -         ..
270737 -        Date Spec taken: Jul 07, 2020        Pathologist:MARY MEIGHAN TOMIC MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270738 -        Date Spec rec'd: Jul 09, 2020 09:32  Resident: YING LIU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270739 -        Date completed: Jul 13, 2020         Accession #: SP 20 3501                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270740 -        Submitted by:                        Practitioner:RANDALL E LEE MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270741 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270742 -        ==============================================================                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270744 -         ..
270745 -        Specimen:             A. CECUM BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270746 -        B. ASCENDING COLON BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270747 -        C. TRANSVERSE COLON BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270748 -        D. SPLENIC FLEXURE BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270749 -        E. DESCENDING COLON BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270750 -        F. SIGMOID COLON BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270751 -        G. RECTUM BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270752 -        Date Obtained:        07 Jul 2020                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270753 -        Performing Location:  No CA Healthcare Sys-Martinez150 Muir Road, MARTINEZ 94553                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270754 -        Date Completed:       13 Jul 2020                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270755 -        -------------------------------------------------------------------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270757 -         ..
270758 -        SURGICAL PATHOLOGY REPORT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270760 -         ..
270761 -        Reporting Lab: SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270762 -        10535 HOSPITAL WAY MATHER, CA 95655-4200                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270764 -         ..
270765 -        Date Spec taken: Jul 07, 2020        Pathologist:MARY MEIGHAN TOMIC MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270766 -        Date Spec rec'd: Jul 09, 2020 09:32  Resident: YING LIU                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270767 -        Date  completed: Jul 13, 2020        Accession #: SP 20 3501                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270768 -        Submitted by:                        Practitioner:RANDALL E LEE MD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270769 -        -------------------------------------------------------------------------                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270771 -         ..
270772 -        Specimen:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270773 -        A. CECUM BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270774 -        B. ASCENDING COLON BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270775 -        C. TRANSVERSE COLON BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270776 -        D. SPLENIC FLEXURE BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270777 -        E. DESCENDING COLON BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270778 -        F. SIGMOID COLON BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270779 -        G. RECTUM BX                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270780 -        Brief Clinical History:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270781 -        DIAGNOSTIC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270782 -        Preoperative Diagnosis:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270783 -        75 YO MAN; CAD, LONG DISTANCE HIKER.  RECENT ISCHEMIC COLITIS.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270785 -         ..
270786 -        Operative Findings:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270787 -        EGD/COLONOSCOPY                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270788 -        Postoperative Diagnosis:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270789 -        CECUM NORMAL. ASCENDING COLON: PATCHY ERYTHEMA & ULCERS. ?ISCHEMIC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270790 -        TRANSVERSE COLON: NORMAL. SPLENIC FLEXURE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270791 -        ULCERATION. ?CHRONIC ISCHEMIA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270792 -        VS NEOPLASM. DESCENDING COLON: NORMAL. SIGMOID COLON: NORMAL. RECTUM:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270793 -        NORMAL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270795 -         ..
270796 -        Gross description:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270797 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270798 -        A.  Received in formalin with proper patient identification                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270799 -            labeled "cecum biopsy" are two fragments of tan-grey tissue                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270800 -            measuring 0.2 x 0.2 x 0.2 cm and 0.2 x 0.1 x 0.1 cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270801 -            Totally submitted in one cassette.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270803 -             ..
270804 -        B.  Received in formalin with proper patient identification                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270805 -            labeled "ascending colon biopsy" are two fragments of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270806 -            tan-grey tissue measuring 0.3 x 0.2 x 0.2 cm and 0.2 x 0.1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270807 -            x 0.1 cm.  Totally submitted in one cassette.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270809 -             ..
270810 -        C.  Received in formalin with proper patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270811 -            identification labeled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270812 -            "transverse colon biopsy" are three fragments of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270813 -            tan-grey tissue                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270814 -            measuring 0.3 x 0.3 x 0.2 cm, 0.3 x 0.2 x 0.2 cm and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270815 -            0.2 x 0.2 x 0.1 cm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270816 -            Totally submitted in one cassette.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270818 -             ..
270819 -        D.  Received in formalin with proper patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270820 -            identification labeled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270821 -            "splenic flexure biopsy" are multiple fragments                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270822 -            of tan-grey tissue                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270823 -            measuring 1.0 x 0.4 x 0.2 cm in aggregate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270824 -            Totally submitted in one                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270825 -            cassette.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270827 -             ..
270828 -        E.  Received in formalin with proper patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270829 -            identification labeled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270830 -            "descending colon biopsy" are multiple                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270831 -            fragments of tan-grey tissue                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270832 -            measuring 0.6 x 0.5 x 0.2 cm in aggregate.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270833 -            Totally submitted in one                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270834 -            cassette.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270836 -             ..
270837 -        F.  Received in formalin with proper                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270838 -            patient identification labeled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270839 -            "sigmoid colon biopsy" are three fragments of tan-grey tissue measuring                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270840 -            0.3 x 0.3 x 0.2 cm, 0.3 x 0.2 x 0.2 cm and 0.2 x 0.1 x 0.1 cm. Totally                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270841 -            submitted in one cassette.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270843 -             ..
270844 -        G.  Received in formalin with proper patient identification labeled                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270845 -            "rectum biopsy" is a single fragment of tan-gray tissue measuring 0.4 x                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270846 -            0.3 x 0.3 cm. Totally submitted in one cassette.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270847 -            (YL 7/9/2020 10:54 AM)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270848 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270850 -         ..
270851 -        Microscopic exam/diagnosis: (Date Spec taken: Jul 07, 2020                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270852 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270853 -        A.  COLON, CECUM (BIOPSY): BENIGN COLONIC MUCOSA WITH                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270854 -            INCREASED                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270855 -            EOSINOPHILS, SEE COMMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270856 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270857 -        B.  COLON, ASCENDING (BIOPSY): LAMINA PROPRIA AND                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
270858 -            SURFACE EPITHELIAL ACUTE                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270859 -            INFLAMMATION, SEE COMMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270861 -             ..
270862 -        C.  COLON, TRANSVERSE (BIOPSY): LAMINA PROPRIA AND                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270863 -            SURFACE EPITHELIAL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270864 -            ACUTE INFLAMMATION WITH REACTIVE EPITHELIAL                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270865 -            CHANGE, SEE COMMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270867 -             ..
270868 -        D.  COLON, SPLENIC FLEXURE (BIOPSY):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270869 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270870 -            - GRANULATION TISSUE CONSISTENT WITH ULCER                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270871 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270872 -            - LAMINA PROPRIA AND SURFACE EPITHELIAL ACUTE INFLAMMATION WITH                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
270873 -              REACTIVE EPITHELIAL CHANGE, SEE COMMENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270875 -             ..
270876 -        E.  COLON, DESCENDING (BIOPSY): NO DIAGNOSTIC ALTERATION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270878 -             ..
270879 -        F.  COLON, SIGMOID (BIOPSY): NO DIAGNOSTIC ALTERATION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270881 -             ..
270882 -        G.  COLON, RECTUM (BIOPSY): NO DIAGNOSTIC ALTERATION                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270883 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270885 -         ..
270886 -        COMMENT:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270887 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270888 -        1.  For part "A," there is an apparent increase in eosinophils                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270889 -            in the lamina propria and occasional crypts show                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
270890 -            intraepithelial eosinophils as well.  The clinical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270891 -            significance of this finding is unclear.  It may reflect                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270892 -            the same underlying phenomenon that is driving the changes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270893 -            seen in the ascending colon, transverse colon and splenic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270894 -            flexure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
270896 -             ..
270897 -            The biopsies from these sites show predominantly lamina                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270898 -            propria and surface epithelial acute inflammatory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
270899 -            infiltrate without evidence of chronicity.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270901 -             ..
270902 -            Evidence of epithelial injury is also seen.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270904 -             ..
270905 -            These findings suggest a differential diagnosis of drug                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
270906 -            effect (i.e.  NSAIDs), infection and ischemia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
270908 -             ..
270909 -            Specific features of ischemic colitis, however are not                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
270910 -            seen.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
270912 -             ..
270913 -            The possibility that the findings reflect an early                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270914 -            presentation of inflammatory bowel disease cannot be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270915 -            entirely excluded.  Clinical and endoscopic correlation is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270916 -            required.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
270918 -             ..
270919 -        2.  Dr Patricia Dalton has reviewed parts C and D of this case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
270920 -            and concurs.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
270922 -         ..
270923 -        Performing Laboratory:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
270924 -        Surgical Pathology Report Performed By:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
270925 -        SACRAMENTO VA MEDICAL CENTER [CLIA# 05D0988241]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
270926 -        10535 HOSPITAL WAY MATHER, CA 95655-4200                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270927 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270928 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270929 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270930 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270931 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270932 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270933 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270934 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270935 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270936 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270937 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270938 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
270939 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
2710 -